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Background The new reality of biologic terrorism and warfare has ignited a debate about whether to reintroduce smallpox vaccination.
Methods We developed scenarios of smallpox attacks and built a stochastic model of outcomes under various control policies. We conducted a systematic literature review and estimated model parameters on the basis of European and North American outbreaks since World War II. We assessed the trade-offs between vaccine-related harms and benefits.
Results Nations or terrorists possessing a smallpox weapon could feasibly mount attacks that vary with respect to tactical complexity and target size, and patterns of spread can be expected to vary according to whether index patients are hospitalized early. For acceptable results, vaccination of contacts must be accompanied by effective isolation. Vaccination of contacts plus isolation is expected to result in 7 deaths (from vaccine or smallpox) in a scenario involving the release of variola virus from a laboratory, 19 deaths in a human-vector scenario, 300 deaths in a building-attack scenario, 2735 deaths in a scenario involving a low-impact airport attack, and 54,729 deaths in a scenario involving a high-impact airport attack. Immediate vaccination of the public in an attacked region would provide little additional benefit. Prior vaccination of health care workers, who would be disproportionately affected, would save lives in large local or national attacks but would cause 25 deaths nationally. Prior vaccination of health care workers and the public would save lives in a national attack but would cause 482 deaths nationally. The expected net benefits of vaccination depend on the assessed probability of an attack. Prior vaccination of health care workers would be expected to save lives if the probability of a building attack exceeded 0.22 or if the probability of a high-impact airport attack exceeded 0.002. The probability would have to be much higher to make vaccination of the public life-saving.
Conclusions The analysis favors prior vaccination of health care workers unless the likelihood of any attack is very low, but it favors vaccination of the public only if the likelihood of a national attack or of multiple attacks is high.
Source Information
From the RAND Center for Domestic and International Health Security, Santa Monica, Calif. (S.A.B., R.B., E.B.K., S.C.M.), and Arlington, Va. (J.L.B., M.A.S.); the Center for Research in Patient-Oriented Care, Veterans Affairs San Diego Healthcare System and the University of California, San Diego, San Diego (S.A.B., V.B.); and Erasmus University, Rotterdam, the Netherlands (R.B.).
This article was published at www.nejm.org on December 19, 2002.
Address reprint requests to Dr. Bozzette at RAND Health Care, 1700 Main St., Santa Monica, CA 90407-2138, or at sam_bozzette{at}rand.org.
Related Letters:
Smallpox and Smallpox Vaccination
Letai A. G., Snyder K. M., Fett J. D., Worthington M. G., Ross J. J., Neff J. M., Lane J. M., Fulginiti V. A., Milton D. K., Bozzette S. A., Boer R., Mack T., Sepkowitz K. A.
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N Engl J Med 2003;
348:1920-1925, May 8, 2003.
Correspondence
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